Tendon Rupture

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Tendon ruptures can usually be diagnosed by clinical assessment. X-rays and ultrasound are used to establish or confirm the diagnosis but MRI gives the most definitive information about the nature and extent of the rupture.

Tendon ruptures are uncommon but may cause severe initial pain and lead to permanent disability if untreated. Management may be surgical or non-surgical depending on the site and severity of the rupture and the clinical features and disability caused by the rupture.

Patients aged over 60 years are more prone to tendon damage and therefore tendon rupture. Younger people can also be at increased risk associated with sporting activities.

Tendon damage (including rupture) has been reported rarely in patients receiving quinolones (eg, ciprofloxacin, ofloxacin, levofloxacin).[1]Tendon rupture may occur within 48 hours of starting treatment but has also been reported several months after stopping a quinolone. The risk of tendon damage is increased by the concomitant use of corticosteroids. Quinolones are therefore contra-indicated in patients with a history of tendon disorders related to quinolone use. If tendonitis is suspected, the quinolone should be discontinued immediately.

The most common tendon ruptures are discussed below. Achilles Tendonitis and Rupture are discussed in greater detail in a separate article. Shoulder rotator cuff tears are discussed in the separate article Shoulder Pain.

Proximal biceps tendon rupture

Ruptures of the proximal biceps tendon make up nearly all biceps ruptures. Proximal biceps tendon rupture is usually transverse and either within the shoulder joint or within the proximal part of the intertubercular groove. The prognosis for biceps tendon ruptures is good for both surgical repair and for conservative management.

Presentation

The biceps muscle bunches up in the distal arm, causing the characteristic 'Popeye muscle' appearance. There is minimal loss of function.

Management

Patients are often treated conservatively.[2]Most will become asymptomatic after 4-6 weeks. Patients may benefit from non-steroidal anti-inflammatory drugs and physiotherapy.

There are no generally agreed guidelines for the role of surgical repair but tenodesis and proximal subacromial decompression (or distal reattachment) may be required for young or athletic patients, or for persons who require maximum supination strength.

Distal biceps tendon rupture

Distal biceps tendon rupture is usually caused by a single traumatic event involving flexion against resistance, with the elbow at a right angle.

Complications

Patellar tendon rupture

Patellar tendon rupture is usually unilateral and due to a sports injury in patients younger than 40 years.

Bilateral ruptures, with more minor trauma, can occur in patients with systemic conditions such as inflammatory disease, diabetes mellitus or chronic kidney disease.

Presentation

There is an immediate onset of pain with a tearing sensation.

Diffuse tender swelling with bruising develops in the anterior knee.

A defect at the level of the rupture may be palpable.

Active extension may be completely lost and the patient unable to maintain the passively extended knee against gravity.

Management

Conservative management has a very limited role but may be indicated for the rare case of partial patellar tendon tear (cast or brace immobilisation in full extension for six weeks, followed by physiotherapy).

Immediate surgical repair of the ruptured patellar tendon is recommended for optimal return of function. The outcome is closely related to the length of time between injury and repair.[6]If the tendon is repaired immediately, most patients experience nearly full return of knee motion.

Quadriceps tendon rupture

Quadriceps tendon rupture is relatively infrequent and usually occurs in patients older than 40 years.

Spontaneous rupture may occur. The most common mechanism is a simple fall.[7]

Presentation

Patients typically present with acute knee pain, swelling and functional loss following a stumble, fall or giving way of the knee.

There may be no history of prior knee pain. Suprapatellar swelling, bruising and tenderness are present.

There is also variable loss of knee extension.

Management

Early surgical repair yields the best results for complete quadriceps tendon ruptures.

Partial tears can be treated conservatively with rest, analgesia and physiotherapy.

Posterior tibial tendon rupture

The posterior tibial tendon maintains the arch of the foot and posterior tibial tendon rupture is one of the most common causes of acquired flat foot in adults.

The foot may become so deformed that severe ankle arthritis develops.

Presentation

Arch supports and heel cups are usually ineffective in relieving symptoms. The objective is to reduce excessive midfoot motion, using total contact orthosis supporting the longitudinal arch, and a medial heel wedge.

Article Information

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